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CAMHS won't see you now

Should GPs charge for DNAs? No

GPs should not charge for missed appointments, argues Dr Jonny Tomlinson, as such a policy hits vulnerable and deprived patients hardest

The introduction of fines for no-shows – either in terms of a refundable fee for making an appointment, or a charge after non-attendance – is an example of a zombie policy.

Zombie policies, like user-charges for healthcare, are repeatedly resurrected and killed. No matter how many times we defeat them, they keep coming back.

No matter how heavily armed I am with evidence or how deadly my arguments, these policies will not stay dead. Never mind  how loosely assembled they are. Their limbs fall off with a slight tug or a casual wallop with a shovel, or they auto-decapitate with an accidental bump on a low doorway. Never the less they rise up again with a single brainless purpose, ‘We … will … punish the non-attenders…’.

Zombies and zombie policies have a cult following. Some evidence for charging for no-shows comes from a government e-petition set up last year which suggested that patients who DNA ‘should be given a small fine such as £30 or £50 – this will encourage patients to attend appointments or cancel them if they don’t need them’.1 The overwhelmingly enthusiastic respondents who have commented raise another important zombie theme, moral outrage. Moral outrage is usually more apparent when there is no evidence to be debated.

According to the comments after the e-petition, patients who DNA are ‘time-wasters’, ‘abuse the system’, ‘inconvenience other patients’, ‘don’t care’, ‘cost millions’ and so on. A few people tried to raise concerns about the poor, vulnerable, elderly, forgetful and so on, but were outnumbered by those cheering for the policy.

Perhaps the most thoughtful analysis of why patients do not attend psychiatric outpatient appointments concluded that, ‘low and high illness severity predict non-attendance. In other words the most common reason for not attending a first appointment is feeling better but the most serious is feeling too unwell’.2 Patients with mental health problems are the most frequently encountered in general practice, accounting for 30–40% of all appointments. In deprived areas, rural and urban, the proportions are higher. In other words, zombie policies are a good way of impoverishing people with mental illnesses that are having a bad day.

Armed with this knowledge, a more humane response to a patient who fails to attend would be to phone them up and ask them if they are OK. Patients who are contemplating suicide might discover the will to live, and patients who forgot might be invited in to discuss their failing memory, or otherwise feel adequately chastened so that they don’t do it again.

If you take continuity of care seriously, then the patient will have their own doctor and a call can be a powerful force for good. But is it an evidence-based intervention for reducing patient DNAs? Who knows? We also have a range of other access interventions including texting, emailing, not booking appointments too far in advance, allowing patients to choose times that are convenient for them, and so on. For example, one system claims that as well as reducing DNA rates by 80%, it also reduces A&E attendances and doctor stress, and lowers patient waiting times.3

But zombies are by definition brain-dead, and cannot be fought with arguments about making things better for patients. For them, the fundamental point is that, ‘patients who do not attend are bad, and need to be fined’. Theirs is a moral vacuum, a market society where money governs social relations.4

The final lesson about zombies – and the reason we cannot kill them – is that they are a reminder of what we have ourselves become: stripped away of complexity, in all our horror.

Dr Jonny Tomlinson is a GP in Hackney.

Click here to read why Dr Richard van Mallaerts thinks GPs should charge for DNAs.


1 E-Petition call to charge DNA patients.

2 Mitchell, Selmes. Why don’t patients attend their appointments? Maintaining engagement with psychiatric services  Advances. Psychiatric Treatment. 2007. 13: 423-434 doi: 10.1192/apt.bp.106.003202

3 Patient Access.

4 Sandel, M. What Money Can’t Buy: The Moral Limits of Markets. The Atlantic, April 2012.

Readers' comments (7)

  • Jamie Green

    I have no interest in charging patients for appointment, regardless of if they attended.

    Those patients who miss appointments are often those is a vulnerable position, leading a disordered lifestyle. These would be hardest hit, and this would cause deeper health inequality.

    Should be take DNA more seriously, yes. But engagement with these patients is key.

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  • Totally agree - finding out why patients DNA is the key

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  • Mark Struthers

    Good on you, Jonny! Kind, sensible, reasoned argument – I’m impressed!

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  • The loss of continuity has a part to play.....'the doctor will see you now' .which one?.if they don't give a stuff and have no idea who you = are the attitude is likely to be reciprocated

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  • Mark Struthers

    Jonny may agree that 'capital punishment' is another example of a zombie policy that keeps bouncing back. Next week we're being asked to elect
    law enforcement officers who promise they'll restore the death penalty for police murderers, paedophiles and paediatricians. Two cheers for democracy.

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  • Harry Longman

    Charging for DNAs would have the unintended consequence of driving more patients to expensive secondary care sites. Better to understand the reasons for DNAs, abundantly clear when you measure the DNA rate vs days between booking and appointment. It's a line through the origin. So when there is no delay, people turn up. Bingo!

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  • Realistically, those patients most likely to DNA are those who find life difficult enough already. Only occasionally is a DNA likely to be someone who "can't be bothered" to cancel or inform of non-attendance. Besides, would it not cost more to try and collect such a fine? And would non-payment result in a visit from the bailiffs? Would it not discourage vulnerable people from seeking help at all if they think they may end up with (yet more?) debt or have a "black mark" against their GP/hospital records? My local GP surgery has rolling signs in the surgery . I have seen notices reminding patients of how many appointments were wasted the previous month - a reminder there is a cost to uncancelled non-attendances and that Doctors' time is valuable. Surely that's enough. The vulnerable in our society have enough difficulty reaching out for help. Let's not put additional barriers in the way, please.

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